APPLICATION FOR COMPENSATION GENERAL INSURANCE

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "APPLICATION FOR COMPENSATION GENERAL INSURANCE"

Transcription

1 Barcode APPLICATION FOR COMPENSATION GENERAL INSURANCE Liquidator s ROP Claim reference number: ROPLEM (please quote when contacting us): Name of the firm you are claiming against: Lemma Europe Insurance Company Limited (In the form, we call this organisation "the firm") Please write clearly in CAPITALS using BLACK ink only. Answer each or question by ticking the appropriate box. SECTION A NAME & ADDRESS DETAILS Q1 Name Current address Telephone No. Town County Postcode COUNTRY United Kingdom Q2 Are you making this claim as an individual private policyholder or an individual(s) T/As (i.e. rather than on behalf of a company, firm or corporation)? Go to section B Go to section C - 1 -

2 SECTION B CLAIMANT DETAILS CLAIMANT 1 CLAIMANT 2 Q3 Is someone else claiming with you? Title, First Names and Surname Please provide their details under claimant 2 Q4 Date of birth (dd/mm/yyyy) Q5 Current occupation (Please state if retired) Q6 Please provide your National Insurance number Q7 Current marital status (Please tick one box) Single Widowed Living with partner Single Widowed Living with partner Married Divorced Separated Married Divorced Separated Q8 If married, please provide previous surname(s), if applicable Q9 Relationship between claimant 1 and 2 If there are more than two claimants, please give details of the other claimants on pages 10 and 11 Q10 All contact number(s). (Please give at least one contact number) Home Work Mobile Fax Best time to call Home Work Mobile Fax Best time to call Q11 address address Q12 Do you have a representative or are you the Executor / Administrator? Go to section D Go to section E - 2 -

3 SECTION C Firm or Business Q13 Are you making this claim for compensation as: - a firm or other business, such as an incorporated body or partnership? Go to Q14 - an overseas financial services institution? Go to Q14 - the operator/trustee of a Collective Investment Scheme? Go to Q14 - the trustee of a pension/retirement fund? Go to Q14 - a supranational institution / government / central administrative authority? Go to Q16 - a provincial / regional / local / municipal / authority? Go to Q16 Q14 Please give your company number or confirm your partnership status. Please tell us the nature of the business: Please provide details of any subsidiaries: (If you do not have enough space, please continue on a separate sheet. Pages 10 and 11 can be used for this) Q15 Please confirm your firm s annual turnover for the financial year in which the insurance policy, for which you are claiming, commenced (please supply suitable evidence of the position, such as audited accounts where possible). If that financial year is not yet complete, please provide us with your firm s annual turnover for the previous complete financial year. Q16 Are you making this claim for compensation as: - a corporate body established by law? (eg a company set up under a specific Statute EXCLUDING the Companies Act) - under national ownership or control? - subsidiary of any of the above? Q17 Has the policyholder ever been exempt, or are they currently exempt from the requirements to maintain Employers Liability Insurance under the Employers Liability (Compulsory Insurance) Act 1969? - 3 -

4 Q18 Are you aware of any incident(s) or circumstances which may give rise to a claim under the policy in the future? Please provide details Q19 Do you have a representative or are you the Executor / Administrator? Go to section D Go to section E - 4 -

5 SECTION D ONLY COMPLETE THIS SECTION IF YOU ARE T THE CLAIMANT Q20 In what capacity are you making this claim? Please tick one box Executor/administrator Go to Q21 Other Go to Q23 Representative Go to Q23 Q21 What was the date of the policyholder s death? (dd/mm/yyyy) Please enclose the original Death Certificate Please tick the box if a Death Certificate is enclosed Q22 What other original documents are you enclosing? Tick all that are enclosed. At least one is required. Will Grant of Letters of Administration Q23 Grant of Probate Confirmation of Estate (FOR SCOTTISH CLAIMANTS ONLY) Go to Q23. Please complete the rest of this form as fully as possible. Please complete this question if you are making this claim as a representative appointed by the policyholder(s), or in a different capacity, e.g. you have Power of Attorney. Please ask the policyholder(s) to sign the declaration below. Or please provide original documents in support of your position as a representative of the policyholder(s). Please tick this box if original documents are enclosed I/We wish the following person or firm to *receive a copy of all correspondence/act on my/our* behalf in making this claim (*please delete as appropriate) Signed.... Date. Signed.... Date. Q24 If you are not the policyholder, but their representative for this claim, please give: Your contact name Company name if applicable Address Town County Postcode COUNTRY Contact number day time Fax number address Ref - 5 -

6 SECTION E THE CLAIM Q25 Is the claim being made against you? Go to Q27 Go to Q26 Q26 Is the person making the claim against you now, or have they ever been: - a director of the firm? If yes to any of the above please provide details below Q27 What type(s) of policy(ies) are you claiming against? Please tick all boxes that apply Employers Liability Public Liability Household Motor Professional Indemnity Other If other, please give details Q28 Please give details of the policy(ies) for which you are claiming compensation Please include a copy of the policy documents, if available. If you don t have details of your policy(ies), please contact the insurance company or your broker. Type of policy Policy number Start date dd/mm/yy End date dd/mm/yy Q29 Were any of the premiums paid by credit card or other finance arrangement? If yes, please provide a copy of the credit card receipt or credit finance agreement, if available Please tick the box if a copy is enclosed - 6 -

7 Q30 Have you received a payment / other benefit from another insurer or a third party? (If yes, please provide details) Q31 Have you ever made any other claims to the Financial Services Compensation Scheme (FSCS) or to the Policyholders Protection Board (PPB)? (If yes, please give details, including reference(s)): - 7 -

8 You must answer all the following questions or this form will be returned to you Q32 Are you now, or have you been at any time in the past: Please tick here Tick here if you are enclosing copy correspondence a director of the firm your claim is against? If yes, please give details, including whether you received a salary or other remuneration for your services to the firm Q33 Has the firm Lemma Europe Insurance Company agreed to pay you compensation? Q34 Do you owe any money (e.g. premium) to the firm? Q35 Have you been offered compensation on this matter by anyone else? Q36 Are you getting legal aid (public funding) to help you with your claim? Q37 Have you started legal proceedings against the firm or any connected party? Q38 Have you entered into arbitration with the firm or any connected party? Q39 Have you complained to the Financial Ombudsman Service regarding the firm or any connected party? Now please turn over and sign the Declaration and Consent at Q40-8 -

9 SECTION F DECLARATION AND CONSENT Q40 Please read the following Declaration and Consent carefully. You must sign and date this section to proceed with your claim. Declaration: The information given by me/us to the Financial Services Compensation Scheme Limited ( FSCS ) in support of my/our claim is true and correct to the best of my/our knowledge and belief. I/We declare that the transaction giving rise to this claim was not made in the course of, or for the purpose of, money laundering, disposing of the proceeds of crime, or any criminal activity. Consent: I/We consent to FSCS and the Prudential Regulatory Authority ( PRA ) processing, receiving and requesting any information and documents as they may need in connection with my/our claim for compensation or in carrying out their statutory function. I/We authorise any other person or organisation to release such information and documents to FSCS and to the PRA. I/We also consent to the FSCS releasing or disclosing information and documents about me/us and my/our claim to any other person in carrying out its statutory function, or to the PRA or as otherwise required by law. Explanations applying the Declaration and Consent: FSCS includes its officers, employees, servants and agents. PRA may act as an agent of FSCS or on its own behalf. Information and documents include personal data and sensitive personal data as defined in data protection law. The information and documents may be provided to FSCS or the PRA by any person. Except as stated above, FSCS will process information about you and your claim in accordance with data protection law. You can download copies of our data protection statement from our website ( or get them from our Customer Services Team by telephoning Claimant 1 Signed Date Name.. (CAPITAL LETTERS PLEASE) Are you authorised to sign on behalf of the Company? If so in what capacity. (Please provide proof of authority)... Claimant 2 Signed Date Name.. (CAPITAL LETTERS PLEASE) Before you send this form back to us, please read the checklist on the next page

10 CHECKLIST Have you completed all the questions that apply to your claim? Have you signed and dated the form at Q40? Has Claimant 2 (where applicable) signed and dated the form at Q40? Have you enclosed copies of all correspondence that you wish us to consider? Have you enclosed the originals of important certificates (e.g. Death Certificate, Change of Name by Deed Poll, Power of Attorney) We will return them to you when we have reviewed them. Have you enclosed a copy of your accounts? Have you attached securely to this form any additional pages of information and put the FSCS reference on each one? Do you have documents at home that you have been unable to copy and send to us, which support your claim for compensation? Please tick Return the entire form to us, with any additional pages firmly attached. Send it to: Freddie White Liquidator Lemma Europe Insurance Company Limited ROP Claims Grant Thornton (Gibraltar) Limited 6A Queensway P.O. Box 64 Gibraltar

11 Please use this page if you did not have enough space under any of the questions to write your answer

12 Please use this page if you did not have enough space under any of the questions to write your answer. If additional space is needed, please continue on a separate sheet. Attach separate sheet securely to this form and write the Liquidator s ROP Claim reference number clearly on each

Online Accounts. Power of Attorney application form. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney

Online Accounts. Power of Attorney application form. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney Online Accounts Power of Attorney application form Please read these notes before you fill in this form The account will be operated strictly in accordance with the instructions confirmed within the Power

More information

Online Accounts. Power of Attorney application form. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney

Online Accounts. Power of Attorney application form. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney Online Accounts Power of Attorney application form Please read these notes before you fill in this form The account will be operated strictly in accordance with the instructions confirmed within the Power

More information

60 Day Notice Business Savings Account Issue 4-Application Form

60 Day Notice Business Savings Account Issue 4-Application Form 60 Day Notice Business Savings Account Issue 4-Application Form Please complete this form in BLOCK CAPITALS and in ink. Account Number (For bank use only) I/We would like to invest into a 60 Day Notice

More information

Compulsory Purchase Annuity

Compulsory Purchase Annuity Application form Who this form is for 0615 This form is for people who want to purchase a pension from Standard Life Filling in this form Before completing this form read the Key Features Document (CPA17)

More information

With Profits Pension Annuity

With Profits Pension Annuity With Profits Pension Annuity If you would like help completing your application, please talk to your Independent Financial Adviser. Application form For details about the Liverpool Victoria With Profits

More information

E-ISA. Power of Attorney application form. Personal details. Donor. 1st Attorney Title: Mr, Mrs, Ms, Miss Other (please specify) Surname.

E-ISA. Power of Attorney application form. Personal details. Donor. 1st Attorney Title: Mr, Mrs, Ms, Miss Other (please specify) Surname. E-ISA Power of Attorney application form Please read these notes before you fill in this form The account will be operated strictly in accordance with the instructions confirmed within the Power of Attorney

More information

SSAS application form

SSAS application form SSAS application form By completing this form together with the Trust Deed you agree to appoint Bespoke Pension Management as Scheme Practitioner to your SSAS Scheme. You understand that we will assume

More information

Just Retirement Fixed Term Annuity Application Form

Just Retirement Fixed Term Annuity Application Form Just Retirement Fixed Term Annuity Application Form You should make sure you ve read the Key Features Document and the Conditions of the Just Retirement Fixed Term Annuity before you apply. About this

More information

COMMERCIAL INSURANCE PROPOSAL FORM COVER DESIGNED FOR YOUR BUSINESS

COMMERCIAL INSURANCE PROPOSAL FORM COVER DESIGNED FOR YOUR BUSINESS COMMERCIAL INSURANCE PROPOSAL FORM COVER DESIGNED FOR YOUR BUSINESS This Proposal is for use by special agreement with NIG in connection with their range of Commercial Non-motor Policies other than Motor

More information

Cash ISA Application Form

Cash ISA Application Form Your Information i) We may send your details to credit reference agencies and/or fraud prevention agencies who will supply us with information for the purpose of verifying your identity, including information

More information

95 Day Notice Business Savings Account Issue 4-Application Form

95 Day Notice Business Savings Account Issue 4-Application Form 95 Day Notice Business Savings Account Issue 4-Application Form Please complete this form in BLOCK CAPITALS and in ink. Account Number (For bank use only) I/We would like to invest into a 95 Day Notice

More information

Multi-Platform Open Annuity

Multi-Platform Open Annuity Multi-Platform Open Annuity Application Form Powered by the London & Colonial... Upgradable, Capable, Flexible www.londoncolonial.com Multi-Platform Open Annuity Form To London & Colonial Assurance PLC:

More information

LOAN APPLICATION FORM

LOAN APPLICATION FORM Please select one of these options Reverse Mortgage Investment Property Mortgage Accommodation Bond Loan LOAN APPLICATION FORM FOR EACH APPLICANT Title: Mr Mrs Ms Miss Other: First name: Middle name: Surname:

More information

Savings Account Application Form

Savings Account Application Form Your Information i) We may send your details to credit reference agencies and/or fraud prevention agencies who will supply us with information for the purpose of verifying your identity, including information

More information

Application Form Pure Lump Sum Plan

Application Form Pure Lump Sum Plan Application Form Pure Lump Sum Plan This form is an application for a lifetime mortgage with Pure Retirement Limited. To avoid delays in processing the application, it is important that the form is completed

More information

Online Accounts. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney. Title: Mr, Mrs, Ms, Miss Other (please specify) Surname

Online Accounts. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney. Title: Mr, Mrs, Ms, Miss Other (please specify) Surname Online Accounts Power of Attorney application form Please read these notes before you fill in this form The account will be operated strictly in accordance with the instructions confirmed within the Power

More information

MOTOR TRADE ROAD RISKS ANNUAL DECLARATION COVER ENGINEERED FOR THE MOTOR TRADE

MOTOR TRADE ROAD RISKS ANNUAL DECLARATION COVER ENGINEERED FOR THE MOTOR TRADE MOTOR TRADE ROAD RISKS ANNUAL DECLARATION COVER ENGINEERED FOR THE MOTOR TRADE Motor Trade Road Risks Important Note You (or the broker or agent completing the form on your behalf) must provide all material

More information

Current Account Opening Form for Individuals

Current Account Opening Form for Individuals Current Account Opening Form for Individuals 1 UK LTD. United Kingdom Guidance note for completing Current Account Opening Form for Individuals 1. Please read the terms and conditions very carefully before

More information

DEBTOR FINANCE. Please FAX signed application form back to Nova Business Finance on 1300 138 187

DEBTOR FINANCE. Please FAX signed application form back to Nova Business Finance on 1300 138 187 DEBTOR FINANCE Please FAX signed application form back to va Business Finance on 1300 138 187 va Business Finance is pleased to accept your application with a view to providing you with a solution to your

More information

Group Life Assurance. Change of Policyholder Introduction. Trust and policy details

Group Life Assurance. Change of Policyholder Introduction. Trust and policy details Change of Policyholder Introduction This form allows you to change the policyholder(s)/trustee(s) for a Group Life Assurance Policy for death in service benefits where the scheme only provides death in

More information

Patient complaint form

Patient complaint form Patient complaint form 1 This form is for you to make a complaint, in the strictest confidence, about a doctor to the General Medical Council. You do not have to use this form but, if you do, it will help

More information

Savings account amendment request

Savings account amendment request Savings account amendment request Please use BLOCK CAPITALS and BLACK ink throughout Mark selection boxes clearly with an X if you make a mistake, place a line through the box and then mark the correct

More information

APPLICATION FORM. / / / PENSION ANNUITY. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL

APPLICATION FORM. / / / PENSION ANNUITY. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL PENSION ANNUITY APPLICATION FORM. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL We will already have sent you a quote(s), illustrating the

More information

LIABILITY CLAIM GUIDANCE NOTES

LIABILITY CLAIM GUIDANCE NOTES insuring the UK s triathletes LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of claims made against you

More information

When we receive your claim submission, we will assess it and correspond with you further in due course.

When we receive your claim submission, we will assess it and correspond with you further in due course. Travel Insurance Boots Travel Claims PO Box 60108 London SW20 8US Tel: 0845 125 3820 Fax: 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you

More information

details of anyone complaining with you surname title title d d m m y y y y d d m m y y y y

details of anyone complaining with you surname title title d d m m y y y y d d m m y y y y our ref: payment protection insurance: consumer questionnaire WHAT IS THIS QUESTIONNAIRE FOR? This questionnaire is for consumers to bring a complaint about the sale of payment protection insurance (PPI).

More information

Tradesmen. Hold Cover Summary. Mark Wrighton 139,Borden Lane Sittingbourne KENT ME10 1BY

Tradesmen. Hold Cover Summary. Mark Wrighton 139,Borden Lane Sittingbourne KENT ME10 1BY Mark Wrighton 139,Borden Lane Sittingbourne KENT ME10 1BY AXA Insurance UK Plc 3 Atlantic Quay PO Box 182 Glasgow G2 8JH Tel: 0845 758 1076 Fax: 0870 333 2548 Date of Issue: 24th April 2014 Tradesmen Hold

More information

I/We enclose... to open... Account

I/We enclose... to open... Account Please use black ink if the account is for more than two applicants please use an additional form. Under Society Rules, the first named account holder will be entitled to receive tices of General Meetings

More information

Business account application form for a sole trader

Business account application form for a sole trader Business account application form for a sole trader Internal use only 1. Sole trader Title Forename(s) Surname Trading name (if applicable) Date of birth (dd/mm/yyyy) Mr Mrs Miss Other Town of birth Country

More information

Amendments to your Savings Account

Amendments to your Savings Account Page 1 of 6 Isle of Man Savings Amendments to your Savings Account Please fill in the form using BLOCK CAPITALS and black ink. Tick any boxes which apply. Santander is able to provide literature in alternative

More information

Private Residents Association. Private Road. Public Liability Insurance. Prospectus and Proposal Form IN ASSOCIATION WITH

Private Residents Association. Private Road. Public Liability Insurance. Prospectus and Proposal Form IN ASSOCIATION WITH Private Residents Association Private Road Public Liability Insurance Prospectus and Proposal Form IN ASSOCIATION WITH One policy that meets all your needs Nobody Understands the needs of a residents association

More information

Terms of Business Equity Release Mortgages and Protection Planning

Terms of Business Equity Release Mortgages and Protection Planning Terms of Business Equity Release Mortgages and Protection Planning 1. Introduction This document sets out the terms under which our services are to be provided, including a summary of our charges for those

More information

OEIC Application Form

OEIC Application Form OEIC Application Form Please read the relevant Key Investor Information Document (KIID) and Supplementary Information Document before completing this application form. The Architas Open-Ended Investment

More information

Bridgewater Equity Release

Bridgewater Equity Release Bridgewater Equity Release Home Reversion Plan Application Form Intermediary Checklist An incomplete form may delay the processing of this application. To help assist us, please check: 1. The Intermediary

More information

Crown Equity Release Plan Application Form

Crown Equity Release Plan Application Form Crown Equity Release Plan Application Form Please answer all questions fully in BLOCK CAPITALS in black/blue ink. If the property is owned jointly, for example with your Spouse or Partner, the application

More information

Details of the 3rd party or their representative you feel is responsible for the injury.

Details of the 3rd party or their representative you feel is responsible for the injury. Bupa Travel Insurance Claims AIG Travel PO Box 60108 London SW20 8US Tel: 0330 123 1910* Fax: 0870 130 1950 Dear Sir / Madam So that we may process your claim as quickly as possible please ensure that

More information

LIABILITY CLAIM GUIDANCE NOTES

LIABILITY CLAIM GUIDANCE NOTES LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of claims made against you by any third party, for damage

More information

a P P l I C a N T 1 a P P l I C a N T 2 1. Personal Details 2. any Existing loans/credit Cards* Income Gross basic income/net profit

a P P l I C a N T 1 a P P l I C a N T 2 1. Personal Details 2. any Existing loans/credit Cards* Income Gross basic income/net profit Mortgages Gibraltar HomeOwner Loan Application Form Please complete using BlOCK CaPITalS and tick boxes where appropriate. Enclose a current P60(s)/P7(s), last 3 months payslips/3 years accounts and last

More information

The Charity Bank Savings Account

The Charity Bank Savings Account The Charity Bank Savings Account Application form for individuals Please complete in block capitals and return this form to: Charity Bank, Fosse House, 182 High Street, Tonbridge, Kent TN9 1BE FOR OFFICE

More information

Your name: Name of your business: Your business address:

Your name: Name of your business: Your business address: For mortgage intermediary use only please complete IN FULL Your NBS introducer code: Your name: Name of your business: Commercial mortgage application for a Company Please fill in every answer using block

More information

Elite Retirement Account

Elite Retirement Account Elite Retirement Account Application Form and Mandate for a Self Invested Personal Pension Plan Member Bank Account Self Invested Personal Pension Scheme Account Opening Request To: The Manager, Partnerships

More information

COMPANY / CLOSE CORPORATION / TRUST / PARTNERSHIP MORTGAGE LOAN APPLICATION

COMPANY / CLOSE CORPORATION / TRUST / PARTNERSHIP MORTGAGE LOAN APPLICATION COMPANY / CLOSE CORPORATION / TRUST / PARTNERSHIP MORTGAGE LOAN APPLICATION Tick ( ) applicable block(s) and complete where necessary Indicate: New Loan Pre-Approval Take Over FOR BANK USE ONLY: COMPULSORY

More information

LIABILITY PROPOSAL FORM BUSINESS LIABILITY COVER

LIABILITY PROPOSAL FORM BUSINESS LIABILITY COVER LIABILITY PROPOSAL FORM BUSINESS LIABILITY COVER FOR INTERNAL USE ONLY Agent Name Agency Code When completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALS IMPORTANT

More information

PROFESSIONAL INDEMNITY CLAIM FORM

PROFESSIONAL INDEMNITY CLAIM FORM ACE Insurance Limited PROFESSIONAL INDEMNITY CLAIM FORM McKenna Hampton Pty Ltd "Kandahar House" Level 1, 41-43 Ord Street West Perth WA 6005 PO Box 204, West Perth WA 6872 Phone: 08 6142 0000 Fax: 08

More information

INSTANT SAVER 2 ACCOUNT

INSTANT SAVER 2 ACCOUNT INSTANT SAVER 2 ACCOUNT Provided by Scottish Widows Bank APPLICATION FORM This form is only for the use of personal customers. Account Number (For office use only) Please complete this form in BLOCK CAPITALS

More information

Public and Product Liability. Proposal Form November 2004 Edition

Public and Product Liability. Proposal Form November 2004 Edition Public and Product Liability Proposal Form vember 2004 Edition Important tice To apply for the Public and Product Liability Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point

More information

Novated Lease Application Form

Novated Lease Application Form Novated Lease Application Form Please complete the following details and fax back with the following documents; Privacy Act Consent Form Letter from employer confirming current employment & salary Evidence

More information

Application form Residential and buy-to-let secured loans

Application form Residential and buy-to-let secured loans Together is a trading style of Blemain Finance Limited Application form Residential and buy-to-let secured loans Section 1: Loan details Loan Details Repayment type: (capital & Interest or interest only)

More information

QBE Trade Credit Trade Credit Insurance proposal form

QBE Trade Credit Trade Credit Insurance proposal form QBE Trade Credit Trade Credit Insurance proposal form QBE European Operations Please read the following information carefully This document sets out the important information that you, or your insurance

More information

ORCHESTRALGUARD LIABILITY CLAIM GUIDANCE NOTES

ORCHESTRALGUARD LIABILITY CLAIM GUIDANCE NOTES insuring the UK s orchestral musicians ORCHESTRALGUARD LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of

More information

The Charity Bank Savings Account

The Charity Bank Savings Account The Charity Bank Savings Account Application form for corporates Please complete in block capitals and return this form to: Charity Bank, Fosse House, 182 High Street, Tonbridge, Kent TN9 1BE FoR office

More information

Investment Dealing Account. Corporate Application form for advised clients only

Investment Dealing Account. Corporate Application form for advised clients only Investment Dealing Account Corporate Application form for advised clients only How to complete this form Your adviser can also apply on your behalf for an Investment Dealing Account online at www.alliancetrustsavings.co.uk/adviser

More information

Self-build Insurance. Proposal Form

Self-build Insurance. Proposal Form Introduction DMS SELF-BUILD The Self-build Specialists The Brit Insurance Limited Self-build insurance policy is tailor-made to meet the needs of those building a brand new detached house or bungalow which

More information

Transfer application form

Transfer application form For customers Guaranteed Pension Annuity (tax-free cash) Transfer application form Illustration number Agent number / Agent phone number Agent fax number Agent email address Page 1 of 12 Application checklist

More information

Household Removals Claim form

Household Removals Claim form Household Removals Claim form Notes: The issue of this claim form is not an admission of liability on our part. All questions must be fully answered in either black or blue pen. Please print clearly and

More information

ESTATE PLANNING QUESTIONNAIRE

ESTATE PLANNING QUESTIONNAIRE DATE: _ ESTATE PLANNING QUESTIONNAIRE I. FAMILY AND OCCUPATIONAL DATA: Name: Date of Birth: Address: Citizenship: SS#: Telephone # Home: Work: Cell: Email: Occupation: Name of Employer: Business Address:

More information

Underwritten by. Home Contents Insurance Application Form

Underwritten by. Home Contents Insurance Application Form Underwritten by Home Contents Insurance Application Form Tenants Home Contents Insurance Scheme Application Form Subject to the terms, exclusions and conditions of the policy, a specimen of which is available

More information

RSA Household Insurance Claim Form and Guidance Notes

RSA Household Insurance Claim Form and Guidance Notes RSA Household Insurance Claim Form and Guidance Notes Customer Service Customer Complaints Procedure We are anxious to provide the highest quality of customer service at all times. We are eager therefore

More information

Membership Application OTASA Scheme of Co-operation

Membership Application OTASA Scheme of Co-operation MEDICAL PROTECTION SOCIETY PROFESSIONAL SUPPORT AND EXPERT ADVICE Membership Application OTASA Scheme of Co-operation 012 362 5457 Please complete all parts of this form in BLACK INK and BLOCK CAPITALS

More information

Public / Employer Liability Claim Form

Public / Employer Liability Claim Form Public / Employer Liability Claim Form www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent

More information

Management Liability Policy Employment practices liability only

Management Liability Policy Employment practices liability only February 2014 edition Management Liability Policy Employment practices liability only Who can use this proposal form This proposal form is only for: UK registered companies, charities or associations with

More information

APPLICATION FORM - PERSONAL INJURY (Do not use for fatal injuries)

APPLICATION FORM - PERSONAL INJURY (Do not use for fatal injuries) The Compensation Agency Royston House 34 Upper Queen Street Belfast BT1 6FD www.compensationni.gov.uk THE COMPENSATION Agency Reference number For official use only T1 Criminal Injuries Compensation Scheme

More information

Commercial legal expenses insurance

Commercial legal expenses insurance Commercial legal expenses insurance Proposal form Intellectual property insurance A Partner You Can Trust Please note: Only complete this form if you wish to insure registered intellectual property, i.e.

More information

Davy Select Telephone Trading Account (Execution-Only)

Davy Select Telephone Trading Account (Execution-Only) www.davyselect.ie Davy Select Telephone Trading Account (Execution-Only) Application Form Thank you for choosing Davy Select Please read the accompanying Execution-Only Service Terms (and related documentation)

More information

fleetshield proposal form

fleetshield proposal form fleetshield proposal form FOR OFFICE USE ONLY: Policy.: Authorised: Agency: Broker/Agent: Quote Ref.: premium: A full policy wording is available on request Important: It is an offence under the ROAD TRAFFIC

More information

ABOUT OUR SERVICES AND COSTS

ABOUT OUR SERVICES AND COSTS ABOUT OUR SERVICES AND COSTS 1. The Financial Conduct Authority (FCA) The FCA is the independent watchdog that regulates financial services. This document is designed by the FCA to be given to consumers

More information

Travel Guard Claims PO Box 60108 London, SW20 8US Tel: 0845 603 9892* Fax: 0870 130 1950

Travel Guard Claims PO Box 60108 London, SW20 8US Tel: 0845 603 9892* Fax: 0870 130 1950 Travel Guard Claims PO Box 60108 London, SW20 8US Tel: 0845 603 9892* Fax: 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you fully complete

More information

AIG Life. Whole of Life Insurance. Key Facts

AIG Life. Whole of Life Insurance. Key Facts AIG Life Whole of Life Insurance Key Facts Contents Page Welcome to AIG 3 Section A: About Whole of Life Insurance A1 What is Whole of Life Insurance? 4 A2 Whole of Life Insurance aims 4 A3 How does Whole

More information

Excess Professional Indemnity. Policy document

Excess Professional Indemnity. Policy document Excess Professional Indemnity Policy document Contents A warm welcome to Zurich 3 Your Excess Professional Indemnity policy 3 Section 1 Definitions 5 Section 2 The Cover 5 Section 3 Provisions 6 Section

More information

Client Information and Checklist

Client Information and Checklist Gilham Capital Ltd, PO Box 362, North Ferriby, HU14 9AL Client Information and Checklist *Customer Name(s) *House Number / Name *Street Name Locality *City County *Post Code *Home Telephone Number *Mobile

More information

Supplementary Group Life Policy Application Form

Supplementary Group Life Policy Application Form Supplementary Group Life Policy Application Form Please ensure that you complete all items in each section. Please answer all questions in BLOCK CAPITALS, ticking boxes or circle were appropriate. If you

More information

Secured Loan Application Form

Secured Loan Application Form t e w +44 (0)20 3397 7055 info@arcofinance.co.uk Secured Loan Application Form Section 1: Introducer Details Introducer name: Address: Introducer company: Telephone no: Mobile no: As the Introducing broker

More information

DIRECT TRANSFER ACCOUNT 2

DIRECT TRANSFER ACCOUNT 2 DIRECT TRANSFER ACCOUNT 2 Provided by Scottish Widows Bank APPLICATION FORM Account Number (For office use only) Please complete this form in BLOCK CAPITALS and in ink. APPLICATION CHECKLIST In order for

More information

Register to vote. Go online. Individual Registration Form. You can fill in this form at

Register to vote. Go online. Individual Registration Form. You can fill in this form at Individual Registration Form Register to vote Only one person can register to vote using this form. Go online You can fill in this form at www.gov.uk/register-to-vote Use black ink and write in CAPITALS

More information

Current accounts. Application form for a Gold bank account

Current accounts. Application form for a Gold bank account Current accounts Application form for a Gold bank account Welcome We welcome you to Isle of Man Bank and thank you for choosing us. To help us decide whether we can provide you with the services you have

More information

An ISA may only be held in one individual s name.

An ISA may only be held in one individual s name. When we say we or us, we mean Standard Life Investments (Mutual Funds) Limited. Who is this form for? This form is for anyone who wishes to transfer a Stocks and Shares ISA or a Cash ISA from another ISA

More information

CLAIM FORM TRANSIT esolutions

CLAIM FORM TRANSIT esolutions OFFICE USE ONLY RSA CLAIM NUMBER: LAS Y/N CLAIM FORM TRANSIT esolutions At RSA we know that making a claim can often be a traumatic and confusing experience, but we are dedicated to making this simple

More information

Other. Other (e.g. 1 month) 12 month

Other. Other (e.g. 1 month) 12 month Deposit account application form Trusts Please complete this form in BLOCK CAPITALS and then return to Close Brothers Limited, 10 Crown Place, London EC2A 4FT. All fields are mandatory, unless otherwise

More information

HSC Pension Scheme 1995 Section - Claim for a life assurance lump sum

HSC Pension Scheme 1995 Section - Claim for a life assurance lump sum HSC Pension Service, Waterside House, 75 Duke Street, Londonderry, BT47 6FP HSC Pension Scheme 1995 Section - Claim for a life assurance lump sum (Form AW9 (pre 1.4.08) or AW9 (post 1.4.08) should also

More information

Application Form for Millinium's Wholesale Fixed Income Fund Individual(s) / Sole Trader (Resident/Non Resident)

Application Form for Millinium's Wholesale Fixed Income Fund Individual(s) / Sole Trader (Resident/Non Resident) Before you sign this application form, we wish to give you a Information Memorandum ("IM") which is a summary of important information relating to Millinium's Wholesale Fixed Income Fund ("Fund"). The

More information

3 YEAR FIXED TERM DEPOSIT ACCOUNT

3 YEAR FIXED TERM DEPOSIT ACCOUNT 3 YEAR FIXED TERM DEPOSIT ACCOUNT Provided by Scottish Widows Bank APPLICATION FORM (For office use only) Issue Interest Rate Account Number APPLICATION CHECKLIST In order for us to open your account,

More information

Term Life Insurance Notice of Claim

Term Life Insurance Notice of Claim How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Section A: Insured s/deceased s details Section B: Your details Section C: Family

More information

payment protection insurance: consumer questionnaire

payment protection insurance: consumer questionnaire our ref: payment protection insurance: consumer questionnaire WHAT IS THIS QUESTIONNAIRE FOR? This questionnaire is for consumers to bring a complaint about the sale of payment protection insurance (PPI).

More information

Supplementary Application Form for Short Term Loan (Company)

Supplementary Application Form for Short Term Loan (Company) Supplementary Application Form for Short Term Loan (Company) Broker Name Mobile. Company Email Company Name Property Address Limited Company/LLP Details Correspondence Address (if different to the registered

More information

TRADESMEN PROPOSAL FORM

TRADESMEN PROPOSAL FORM TRADESMEN PROPOSAL FORM FOR INTERNAL USE ONLY Agent Name Agency Code When completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALS IMPORTANT NOTE You (or the broker

More information

Ashworths solicitors

Ashworths solicitors Ashworths solicitors Key details and identification In common with all institutions and bodies that handle client money we are required to verify the identity of our clients. We regard the process of identity

More information

Account Opening Form. Open an Account with Chryson today Benefit from a personalised and professional service

Account Opening Form. Open an Account with Chryson today Benefit from a personalised and professional service Account Opening Form Open an Account with Chryson today Benefit from a personalised and professional service Any investment in CFDs carries a high risk of loss compared to many traditional instruments

More information

APPLICATION & INCOME PAYMENT FORM FOR ANNUITY QUOTATION REF: A Q INCLUDING EXISTING PRUDENTIAL PENSION FUND(S)

APPLICATION & INCOME PAYMENT FORM FOR ANNUITY QUOTATION REF: A Q INCLUDING EXISTING PRUDENTIAL PENSION FUND(S) APPLICATION & INCOME PAYMENT FORM FOR ANNUITY QUOTATION REF: A Q INCLUDING EXISTING PRUDENTIAL PENSION FUND(S) Please add the full reference for the annuity you are accepting. Please use black ink and

More information

Motor Fleet Insurance Proposal Form

Motor Fleet Insurance Proposal Form Motor Fleet Insurance Proposal Form This proposal for motor fleet insurance forms the basis of the contract between you (the Proposer) and us (the Insurer). Failure to disclose all relevant information

More information

Liability Claims Guidance Notes

Liability Claims Guidance Notes Liability Claims Guidance Notes It is important that you read and understand these guidance notes before When can a claim be made against the Council? completing the claim form To successfully claim compensation

More information

Stocks & Shares to Cash ISA Transfer Application

Stocks & Shares to Cash ISA Transfer Application Stocks & Shares to Cash ISA Transfer Application for United trust Bank Title: Forenames: Surnames: Date of birth: Where did you hear about United trust Bank? Please choose one option from the list below:

More information

PART 2 - DETAILS OF THE CLAIM

PART 2 - DETAILS OF THE CLAIM Lifeline Plus Group Personal Accident & Travel Insurance Personal Accident and Sickness Claim Form The claimant should complete and sign this form. If the claimant is under 18 years of age, this form should

More information

POWER OF ATTORNEY SAVINGS ACCOUNT APPLICATION FORM PAGE 1 OF 4

POWER OF ATTORNEY SAVINGS ACCOUNT APPLICATION FORM PAGE 1 OF 4 PAGE 1 OF 4 SECTION 1 - DONOR (PLEASE NOTE, WE WILL OPEN THE ACCOUNT IN THE NAME OF THE DONOR) Are you a permanent UK resident? (Excludes Channel Islands, Isle of Man and other crown dependencies) Please

More information

Excess Directors and Officers Liability. Policy document

Excess Directors and Officers Liability. Policy document Excess Directors and Officers Liability Policy document Contents A warm welcome to Zurich 3 Your Excess Directors and Officers Liability policy 4 Section 1 Agreement with underlying policies 7 Section

More information

Secured Loan Application Form

Secured Loan Application Form Secured Loan Application Form Section 1: Introducer Details Name: Address: Company: Telephone no: Mobile no: Email address: As the Introducing broker are you: A directly authorised firm: An appointed representative:

More information

AIG Life. Business Protection Term Assurance. Key Facts

AIG Life. Business Protection Term Assurance. Key Facts AIG Life Business Protection Term Assurance Key Facts Contents Page Welcome to AIG 3 Section A: About Business Protection A1 What is Business Protection? 4 A2 Business Protection aims 4 A3 How does Business

More information

Small pension taken as a lump sum: repayment claim

Small pension taken as a lump sum: repayment claim Small pension taken as a lump sum: repayment claim About this form Use this form to claim back any tax we owe you on a small pension lump sum payment that you recently received. If you are not a UK resident

More information

Deferred Payment Scheme Application Form

Deferred Payment Scheme Application Form Deferred Payment Scheme Application Form How to complete this application form You will need to fully complete the form starting on page three of this booklet. Please ensure you have read the leaflet Information

More information

Home Insurance Choices Proposal Form.

Home Insurance Choices Proposal Form. Home Insurance Choices Proposal Form. This policy is provided and administered by Legal & General Insurance. Points to remember when completing this form: You need to fully complete all the sections on

More information

Submit the following. Application Form. Complete in full and sign. Please ensure that all declarations are signed and fully completed

Submit the following. Application Form. Complete in full and sign. Please ensure that all declarations are signed and fully completed Personal Loan 3 simple steps to applying for a KBC Personal Loan (Tick when complete) 3 Complete this checklist In order to consider your application for a KBC Personal Loan, please confirm the following:

More information